What is the recommended protocol for safely discontinuing Vyvanse (lisdexamfetamine) to minimize withdrawal symptoms?

Vyvanse (Lisdexamfetamine) Discontinuation Protocol

The safest approach to discontinuing Vyvanse is to implement a gradual tapering schedule over several weeks to months, with dose reductions of approximately 10-20% every 1-2 weeks to minimize withdrawal symptoms.

Understanding Vyvanse Withdrawal

Lisdexamfetamine (Vyvanse) is a prodrug of dextroamphetamine, a Schedule II controlled substance with high potential for abuse and dependence 1. When discontinuing Vyvanse after prolonged use, patients may experience withdrawal symptoms including:

• Dysphoric mood and depression
• Fatigue
• Vivid, unpleasant dreams
• Insomnia or hypersomnia
• Increased appetite
• Psychomotor retardation or agitation 1

Recommended Tapering Protocol

While there are no specific FDA guidelines for Vyvanse tapering, evidence from similar medications suggests a hyperbolic tapering approach is most effective:

1. Initial Phase: Reduce dose by 10-20% of the current dose every 1-2 weeks
2. Later Phase: As doses get smaller, reduce by smaller absolute amounts
3. Final Phase: Extend the interval between doses (e.g., every other day) before complete discontinuation

For example, for a patient on 70mg daily:

• Weeks 1-2: Reduce to 60mg daily (14% reduction)
• Weeks 3-4: Reduce to 50mg daily
• Weeks 5-6: Reduce to 40mg daily
• Weeks 7-8: Reduce to 30mg daily
• Weeks 9-10: Reduce to 20mg daily
• Weeks 11-12: Reduce to 10mg daily
• Weeks 13-14: Alternate 10mg and 0mg before stopping

Special Populations

Renal Impairment

Patients with severe renal impairment (GFR 15 to <30 mL/min/1.73 m²) should not exceed 50mg/day, while those with ESRD (GFR <15 mL/min/1.73 m²) should not exceed 30mg/day 1. For these patients, start tapering from these lower maximum doses.

Elderly Patients

Consider a more gradual tapering schedule (5% reduction every 2 weeks) for elderly patients, as they may be more sensitive to withdrawal effects.

Managing Withdrawal Symptoms

During the tapering process, the following strategies may help manage withdrawal symptoms:

• Sleep disturbances: Implement good sleep hygiene practices
• Mood symptoms: Monitor for depression and consider temporary supportive therapy
• Physical symptoms: Scheduled acetaminophen (not exceeding 3000mg daily) for headaches or discomfort
• Anxiety: Consider non-pharmacological approaches such as cognitive behavioral therapy, regular exercise, and stress management techniques

Monitoring During Discontinuation

• Schedule regular follow-up appointments during the tapering process
• Assess for withdrawal symptoms at each visit
• Monitor for signs of depression or anxiety that may indicate a need to slow the taper
• Be alert for drug-seeking behaviors that may suggest addiction rather than withdrawal

Common Pitfalls to Avoid

1. Tapering too quickly: This is the most common error and can lead to severe withdrawal symptoms
2. Mistaking withdrawal for recurrence of the original condition
3. Using a linear taper rather than a hyperbolic approach that reaches very small doses
4. Failing to adjust the tapering schedule if withdrawal symptoms emerge

While the evidence specifically for Vyvanse tapering is limited, applying principles from research on other medications with withdrawal potential suggests that slower, hyperbolic tapering schedules are more successful in minimizing withdrawal symptoms than short tapers or abrupt discontinuation 2, 3.